MRI uses a magnetic field and radio waves to create images of the prostate. Multi-parametric MRI is a sophisticated method to identify prostate cancers that uses dynamic contrast-enhanced (DCE) MRI and diffusion weighted imaging (DWI) to supplement standard anatomical T1 and T2-weighted imaging. Because of its complexity and subtlety, extensive experience is needed to interpret the results effectively.

The primary reasons to choose a screening MRI next rather than a biopsy are:

Increase the chance of finding the largest and most aggressive cancers that are deadliest.

Reduce the chances of:

Needing a biopsy and

Subsequent cancer diagnosis and possible treatment,

While maintaining the relatively high probability of finding the largest and most aggressive cancers that are deadliest.

Strengthen the case for a biopsy if a tumor is visible on MR images with high MRI Suspicion Score.

MRI Suspicion Scores and Choosing the Scores to Trigger a Biopsy

MR images are often evaluated on a PI-RADS™v2 score from [1] for very low suspicion to [5] for very high suspicion. https://www.acr.org/Quality-Safety/Resources/PIRADS

​Pioneers in multi-parametric imaging for prostate cancers often suggest:

Targeted biopsy for high suspicion scores [4 or 5];

No biopsy for low suspicion scores [1 or 2];

Discussion with the patient based on other evidence for a moderate suspicion score [3].

Prior to making the MRI decision, it is worth deciding how you will respond to a moderate suspicion score [3]. The risks of over-diagnosis and over-treatment from an MRI are less if you plan to delay a targeted biopsy for a moderate suspicion score [3] and are higher if you plan a targeted biopsy in that case.

A high [4] or very high [5] suspicion score means there is a relatively high probability of high-risk cancer and lower probabilities of low-risk or no cancer in the target region of the prostate. Biopsy of target regions with a 4 or 5 suspicion score is currently the best way to diagnose most high-risk cancers with decreased chance of over-diagnosis of lower-risk cancers.

​A biopsy of a region with a moderate suspicion score [3] increases the chance of over diagnosis of low-risk cancer. With a moderate suspicion score [3], a follow-up MRI in a year or two is an alternative to a targeted biopsy now. The risk of over-diagnosis of low-risk cancers increases even more for low [1] or [2] suspicion score regions.​

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Adding a Pattern Biopsy to an MRI Targeted Biopsy

​Some physicians may encourage you to consider adding a conventional pattern biopsy to a targeted biopsy. They might argue that this is the “conservative” approach because the MRI might miss cancers, including possible high-grade cancers (that are likely to be small if missed by MRI).

​Typically, a pattern biopsy added to targeted biopsy offers poor risk tradeoffs. The increased risks of over-diagnosis and treatment from an added pattern biopsy tend to outweigh the benefits of early detection.

​A targeted biopsy does a reasonably good job of identifying the deadliest cancers that tend to be both large and high grade and produce elevated PSA and other biomarkers. An additional pattern biopsy is often left to find the least deadly cancers that are typically small and often low-grade.

If you want to lean toward finding more cancers then the first step is to biopsy moderate suspicion score targets.

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Evaluating a Screening MRI Based on Your Risk Assessment

We have found that evaluating a screening MRI depends on your risk assessment for a conventional pattern biopsy in Q1. Biopsy Delay. Two alternative risk assessments are: A. Prostate cancer risks justify a conventional pattern biopsy now. B. Prostate cancer risks do not justify a conventional pattern biopsy now.We evaluate screening MRI decisions for each of those assessments below.

A. Prostate Cancer Risks Justify a Conventional Pattern Biopsy Now

Use this section if you have assessed the estimated reductions in life expectancy from a 1-year delay in biopsy and concluded that a conventional pattern biopsy is justified now. If used to inform the biopsy decision in this case, a screening MRI has two potential benefits:

Reduce the need for biopsy

Reduce the chance of diagnosis and potential over-treatment

The size of these benefits depends on what MRI Suspicion Scores will trigger a biopsy for you. In order to have already justified a conventional pattern biopsy now, your cancer risks are likely to be elevated and possibly high. For good reason, you may face the following coaching from your physicians:

High MRI Suspicion Score [4 or 5]:

Very strong encouragement to biopsy

Moderate MRI Suspicion Score [3]:

Strong encouragement to biopsy

Low MRI Suspicion Score [1 or 2]:

Weak or no encouragement to biopsy

Therefore, we compare the following two strategies with a conventional pattern biopsy now:

B. Prostate Cancer Risks Do Not Justify a Pattern Biopsy Now

Use this section if you have assessed the estimated reductions in life expectancy from a 1-year delay in biopsy and concluded that a conventional pattern biopsy is not justified now. If used to inform the biopsy decision in this case, a screening MRI has a potential benefit:

Possible justification of a targeted biopsy if the MRI results in a high MRI Suspicion Score or possibly a moderate MRI Suspicion Score

The results of a screening MRI could decrease your apparent risks if MRI Suspicion Score is low and could increase your apparent risks if MRI Suspicion Score is high. A high MRI Suspicion Score may increase your apparent risk enough to justify a targeted biopsy and, therefore, possibly justify a screening MRI to see if the images produce a high MRI Suspicion Score. Our analysis is designed to help you decide if a possible high MRI Suspicion Score changes the analysis enough to justify a biopsy and, therefore, possibly justify a screening MRI now.

Find the Right MRI Supplier for You Based on Quality and Price

​A screening MRI can be expensive, up to $3,000 to $10,000 or more at academic and research centers in the US, and may not be reimbursed by health insurance:

Range of quality and price

Reimbursement varies

Physicians who are teaching MRI to other physicians

Academic and research centers pioneered the use of multi-parametric MRI and remain the leaders in the field with continuing improvement. They found that there was a long learning curve to become expert and fully effective based on 100’s of cases to 1,000 or more cases. Typically, these pioneering academic/research centers tend to charge the highest price.

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Range of Quality and Price

Fortunately, a range of quality and price are becoming available from a growing number of competing suppliers in the US with quality improving with experience.

For example, one private center with extensive experience started by a pioneering urologist at a leading academic center charged only $600 for a screening MRI. If price matters to you, we encourage you to research your options locally, nationally and even internationally.

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Reimbursement Varies

​Reimbursement (or not) by health insurers greatly affects your cost of an MRI. Research by you is required because reimbursement varies greatly, as does price. Screening MRI was often reimbursed early in its development but is increasingly resisted by health insurers. Some will automatically refuse to reimburse a screening MRI, and others will consider it only if a strong case is made on your behalf.

Consider using ultra-sound imaging prior to a screening MRI if your insurance carrier is resistant to reimbursing a screening MRI. Ultra-sound may be reimbursed and provides valuable results that will inform your MRI decision and may help make the case for reimbursement of a screening MRI.

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Physicians Who Are Teaching MRI to Other Physicians

It is difficult to obtain information about MRI suppliers. You can identify some physicians who have been teaching MRI to other physicians through continuing medical education (CME) courses.

Presumably, these teachers are knowledgeable and might be willing to provide information about other physicians who supply MRI closer to your home.